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Tuesday, November 21, 2017

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According to a New York Times article earlier this month, the Affordable Care Act may actually live up to its promise of making health insurance affordable for individuals and families who currently pay too much or are uninsured or underinsured.

As of October 1, 2013, state and federal health exchanges will offer people who cannot get adequate coverage through their employers a marketplace for health insurance coverage at four levels: bronze, silver, gold and platinum. The health plans will be categorized into these levels on the basis of offerings and price. In New York, people who are now paying $1,000 a month for coverage not provided by an employer could pay only $308 a month.

uninsuredSubsidies will be offered according to the person’s ability to pay and the level of the plan they have selected. The silver level will be used as the benchmark. So if someone purchases a gold or platinum level plan, their subsidy will not be as much as those who purchase the bronze or silver plans. And the individual’s or family’s annual gross income will also determine how much the subsidy will be. People with incomes up to 400% of the poverty level will be eligible for subsidies. An individual earning $17,000 a year would pay about $55 a month for the silver plan.

Not all states are forming health exchanges (people living in states that have opted out will be able to access a federal exchange), and those that do are varying in their approach. But California and other states are locking in lower premium prices for insurance coverage offered through their health exchanges (businesses that particiate in the exchange are unlikely to see the same cost reductions, at least for now). How is this happening? First, competition is forcing insurance companies to lower their prices. New players are entering the insurance market, including large health systems such as North Shore-LIJ Health System. Second, the individual mandate and the subsidies will spur more people who previously went without coverage to now buy it.

state health exchanges

Earlier this year, I wrote a blog post for JAMA News Forum on the role of health professionals in educating the public about state health exchanges. This week, someone asked me whether health professionals who oppose “Obamacare” should have to tell their patients and the public about the exchanges and whether they should be able to voice their opposition to the law.

My answer is: It depends.

A recent survey of physicians by, an online job site for physicians, physician assistants and advanced practice nurses revealed that the physicians are not knowledgeable about the state exchanges. In my conversations with physicians and nurses, I’ve found that both groups are woefully uninformed about what’s in the ACA. If the practitioner doesn’t know what’s in the law, then what is the opposition based upon? If someone who opposes the law is truly knowledgeable about what’s in it, how it’s being implemented and what the pros and cons are for the public’s health, then perhaps.

But first and foremost, all health professionals have an ethical responsibility to inform their uninsured patients about the opportunities for obtaining health care coverage. How could you ethically not tell an uninsured patient who has been unable to afford the surgery he needs or get an important diagnostic test that he could qualify for subsidized coverage through a state or federal exchange?

OfriTheresa Brown, BSN, RN, OCN, PhD, is a staff nurse, the author of Critical Care: A New Nurse Faces Death, Life and Everything in Between, an Opinion Columnist for the New York TimesBedside,” and a member of the National Advisory Council for the Center for Health Media and Policy.

Danielle Ofri’s new book What Doctors Feel: How Emotions Affect the Practice of Medicine deserves an award for pulling back the curtain on one of the most taboo topics in health care: difficult feelings. The book is honest and brave, as well as eloquent and compelling. Ofri, a physician at Bellevue Hospital in New York and a frequent contributor to the New York Times, is a talented writer and quite a smart observer of human emotional responses, including her own.

I came to the book as a staff nurse and many of the experiences discussed, as well as the emotional responses they evoked, strongly resonated with me. That’s why I’ve titled this blog post “What Nurses and Doctors Feel,” because even though Ofri’s book focuses on MD’s, nurses can learn a lot from it about our own on-the-job feelings.

 What Doctors Feel begins by exploring how hard it is for Ofri as a new physician to see the humanity in a homeless patient who is dirty, bug infested, and smells terrible. Her feeling of revulsion over the patients’ hygiene makes her unable to care for the patient. Then a nurse’s aide respectfully and gently offers to get the patient cleaned up, locating the human being underneath the patient’s dirty outer layer. Watching the exchange teaches Ofri an important lesson about the barriers to, and importance of, empathy.

This post was written by CHMP Graduate Fellow Amanda Anderson RN, BSN, CCRN

Amanda's Bike Helmet

Recently, I posed the following question to a group of my RN friends on Facebook: “Are you nurses ashamed of being nurses? Why aren’t you telling everybody with an ‘RN’”? You see, I follow my Facebook name with the letters, “RN,” and proudly. In response, my friends told me that they kept their nurse status secret when off the job. Some spoke of liability, others, fears that neighbors would show up with weird spots and bumps on their days off.

These concerns are real, but are they valid? Is nursing something to hide, or is it a vocation that should be shared 100% of the time, in everything we do, in every situation we’re in?

My response to their responses was simply, “How is this any different than walking away from a coding person on the street?” A response, I realize, that is quite direct and some might say harsh, but wouldn’t you consider it valid, too?

I had a lot of pre-conceived notions about poverty and people living in poverty.

These ideas are challenged daily this summer as an intern working at LIFT, a national non-profit whose mission is to help community members achieve economic stability and well-being.

After a comprehensive training orientation with skilled teachers, I have the opportunity to work one-on one with clients in LIFT’s Bronx office to secure housing, employment, public benefits, legal services and financial advising.

In 5 short weeks this experience has educated me and raised my awareness about people living in poverty. The people who come to LIFT as clients are not at all lazy. They work hard every day and come to LIFT because they just need help getting back on their feet.

Having lived through the recession, I think we can all relate to changes in economic security – some folks clearly impacted greater than others – but we all shared common feelings of anxiety, nervousness and panic.

Amanda Anderson is a Graduate Fellow at CHMP

Amanda Anderson 2

There’s a closet in my apartment that I generally tend to avoid. Besides housing my winter coats, it’s where I hide my toolbox and vacuum cleaner. Dark and crowded, every time I venture into it for my hammer, I become instantly angry at the chaos. It’d be easy enough to organize and light, but who wants to do that? Instead, I curse audibly when forced to enter, and all other times avoid it.

While reading about Nelson Mandela’s current clinical status and lack of documented end of life planning, I couldn’t help but think of my disorganized, but highly necessary storage space.

Death is a topic that plagues every living thing, but our society has decided it is worth talking about only when the occasion arises or is near. Hence, we are left, or leave our loved ones, to make decisions that we likely never spoke of in our healthy life. Cramped and disorganized, we’re forced to piece together parts of the puzzle of illness care in the dark; would mom want to live on a ventilator, would dad be okay with a feeding tube, would I want to persist as a vegetable?